Letters to the Editor: Letter to the Editor
To the Editor
In his editorial, Dr. Davis made some valid points about supporting more comprehensive and integrative perioperative care in light of increasing pediatric patient complexity1; however, he believes that the pediatric anesthesiologist is not the person to do so. My question is, why not?
All of us in charge of preoperative planning for children know that it is precisely those 15% of cases about which Dr. Ferrari spoke who require most of our attention during the perioperative period,2 for whom we arrange the transport from home or a medical facility, understand baseline medical complexities, coordinate care with the pediatric intensive care postoperatively to finally get the child back to his or her baseline status, and return the child home. No one knows what happened in the operating room except for the anesthesiologist and the surgical team.
Also, who takes care of these patients when they have left the operating room after a complex procedure during which some specialized trained surgeon and anesthesiologist have taken care of them? Most pediatric and adult hospitals have an adult surgical or a pediatric resident who takes care of these complex patients postoperatively. These patients often present with serious physiologic derangements during the postoperative period that add to the cost of treatment and increase their duration of stay at the hospital.3
We are not talking about excluding the general pediatrician and the whole team of health care specialists (doctors, nurses, physical therapists, etc.) involved in taking care of these children during the perioperative period. We are considering leveraging their input to help us during the perioperative care; however, we are saying that the pediatric anesthesiologist is the best person to help coordinate the care of these complex patients during the entire continuum of the perioperative period.
Dr. Davis also states that it is expensive to teach our advanced training pediatric fellows. It is expensive not to do that, and to allow these advanced fellows to remain inexperienced regarding longitudinal training, evidence-based medicine, biostatistics, and process improvement. Our fellows are required to do a quality improvement project.4 As someone who was trained in the traditional way as a pediatric anesthesiologist, I felt qualified in dealing with the complex pediatric patient in the operating room but had to learn on the job the coordination of the perioperative care. I think that rudiments are important to teach or at least to have an awareness of today’s challenging and changing medical environment. Besides the surgeon, we are the only physicians who know what is happening to the patient in the operating room. Should this help us to become a more specialized physician who is well versed in the care of the child during the perioperative spectrum?
We are in the infancy of the perioperative surgical home. The answers are not all there; some are still being developed. As we have learned through the American Society of Anesthesiologists perioperative surgical home learning collaborative, there are national, local, institutional, departmental, and individual differences and barriers. One size does not fit all. However, Dr. Davis, the emperor has not been wearing clothes for a long, long time. It is time to put some on him.
Vidya T. Raman, MD
Department of Anesthesiology and Pain Medicine
Nationwide Children’s Hospital
1. Davis PJ. The pediatric perioperative surgical home: the Emperor’s new clothes? Anesth Analg. 2015;120:978–9
2. Ferrari LR, Antonelli RC, Bader A. Beyond the preoperative clinic: considerations for pediatric care redesign aligning the patient/family-centered medical home and the perioperative surgical home. Anesth Analg. 2015;120:1167–70
3. Kain ZN, Hwang J, Warner MA. Disruptive innovation and the specialty of anesthesiology: the case for the perioperative surgical home. Anesth Analg. 2015;120:1155–7
4. Nasca TJ, Weiss KB, Bagian JP. Improving clinical learning environments for tomorrow’s physicians. N Engl J Med. 2014;370:991–3